DENVER — Colorado has a serious shortage of primary care and mental health treatment statewide, but experts say some of the state’s plans to address that could at least chip away at the problem.

Despite the perception that provider shortages are a rural problem, none of Colorado’s 21 health regions — including Denver and the surrounding counties — have enough doctors, nurse practitioners and other medical workers to meet their residents’ needs for care, according to data collected earlier this year by the Colorado Department of Public Health and Environment.

Single counties in the metro area are their own regions in the state’s statistics, while less-populated parts of the state are grouped together. The state’s data doesn’t quantify how many more providers each region needs.

Colorado’s best-served regions had enough providers to offer 81% of the primary care visits (in the San Luis Valley) and 72% of the mental health and addiction care (in Denver) that their populations needed, according to the state’s data.

In parts of the high country and the Eastern Plains, the available appointments met one-fifth or less of the need for both types of care.

States can sometimes recruit doctors and other providers from areas that have a greater abundance, but that strategy is expensive, said Joshua Gottlieb, an economist at University of Chicago who has studied health care markets.

Ultimately, states need to either increase the supply of providers, or come up with creative ways to get more out of each one they have, such as having a doctor oversee nurses and technicians who do most of the hands-on care, he said.

“I don’t think we have, as a society, explored how far we can push that,” Gottlieb said.

Colorado has taken steps since the pandemic to increase its supply of providers, including:

•Appropriating almost $247 million in the most recent legislative session for colleges to expand their health care programs, including the creation of a new medical school at University of Northern Colorado

•Paying for classes and materials for community college students going into one of 14 health care careers that require two years of training or less, through the Care Forward Colorado program

•Creating “stackable” micro-credentials that allow students to quickly start working in the mental health field

In most cases, the changes are too recent to see any effects, and UNC’s osteopathic medical school won’t enroll its first class until the fall of 2026.

Only the Care Forward Colorado program, which started in 2022, has some early results, which show about 5,600 people have participated, but only two in five have graduated. That rate is still an improvement over students working toward the same certificates who didn’t receive Care Forward funding, though: less than one in four of them had graduated at the time of the evaluation. Others may graduate in the coming year.

A spokesperson for Gov. Jared Polis’ office said the state is on the right track to fulfilling its health care workforce needs.

“We are saving people money, breaking down barriers to education and training, and developing a stronger workforce to fill in demand jobs and power Colorado’s economy now and in the future,” the governor’s office said in a statement.

Combating shortages is a long-term proposition, to say the least.

Nationwide, almost three-quarters of federally defined health professional shortage areas remained in shortage 10 years after they received that designation, which opened up higher reimbursement rates and loan forgiveness options to physicians willing to work there. (The federal designation only counts physicians and deems an area to have a shortage if the ratio of residents to doctors is above a cutoff, while the state’s numbers include other types of providers.)

Back in the 1980s and ’90s, the country expected an oversupply of physicians, and medical schools cut back in response, said Shoshana Weissman, a fellow at the think tank R Street Institute. That set up the current situation, where essentially all states have shortages somewhere, she said.

Colorado has taken some important steps, such as allowing physician associates to practice without a doctor’s supervision, Weissman said. The state could do more, though, including making it easier for immigrants who were providers in their home countries to find suitable jobs here and allowing pharmacists to provide more routine health services, she said.

“Anything they’re trained to do, they should be allowed to do,” she said.

The state also is trying to bring more people into the behavioral health workforce via “micro-credentials” that let them do entry-level work in mental health and addiction treatment, sometimes after as few as two classes.

Callico Jones, chair of behavioral health at Pueblo Community College, said students have the option of gradually stacking the micro-credentials until they earn a certificate, and then of building on that for a degree in a behavioral health field. Students who’ve completed the micro-credentials typically handle tasks such as helping patients find resources, which allows clinicians to focus on providing treatment, she said.

Pueblo Community College is one of seven offering five possible micro-credentials. About 100 students are enrolled in the college’s behavioral health programs, which also include certificates and an associate’s degree.

While some people in the field are leery of graduates who are taking the new path, it marks a return to the tradition of apprenticeship, since their students will work under licensed clinicians, Jones said. And given the “dire straits” of Colorado’s health workforce, any new professionals will help, she said.

“Before higher education existed, people learned by doing,” she said.

Little research on what works

States have tried a variety of strategies to increase their health care workforces, but they generally haven’t studied which ones work, said Briana Last, a researcher at Stony Brook University in New York who focuses on access to mental health care.

The National Health Service Corps has the most data behind it, and it shows that most people don’t stay in the areas where they served their stint to get loan forgiveness more than five years, she said.

Last’s review of the available studies found each behavioral health provider participating in the corps gave about 1,300 visits per year that the centers where they worked couldn’t have offered otherwise. Only about one-third stayed in the shortage area where they worked after their service time ended, though.

Whether that marks a success in temporarily increasing access or a failure to address shortages in the long term depends on your viewpoint, Last said. While the federal government hasn’t collected much data on why providers leave, incomes tend to be lower in shortage areas and workloads tend to be higher, she said.

“You need to have a bigger carrot” to convince people to stay long-term, she said.

Most of the federal health workforce programs focus on loan forgiveness, but states might have more success if they reduced the cost of getting an education in the first place, via scholarships, Last said.

“A lot of people can’t afford college. A lot of people can’t afford graduate education,” she said.

When UNC’s new osteopathic medicine school is up and running, one of its goals is to work with K-12 schools and local health care providers to create “pipeline” programs that gradually expose kids to health careers, said Dr. Beth Longenecker, the school’s first dean.

Osteopathic doctors, or DOs, learn how to manipulate the muscles and bones, in addition to prescribing medications and performing conventional procedures. While DOs can work in any medical specialty, they tend to pursue primary care because of the field’s emphasis on looking at patients’ wellbeing holistically.

Educating more primary care providers and people willing to work in underserved areas were two of the top reasons funders in Colorado got behind a new medical school, Longenecker said.

“I love the fact that the focus is, how do we recruit students who wouldn’t consider going to medical school,” she said.

The osteopathic medicine school also plans to offer a rural medicine track and set up rotations for students to train at least part-time in federally qualified health centers and in rural and frontier counties, Longenecker said. If they can find the start-up funds, they have the goal of helping providers create 45 residency slots over the next five years, she said.

“If you can have exposure where you can see the impact on a rural community, I think that will inspire our students,” she said.

Where new doctors complete their residency can be at least as important as where they attend medical school, with those who train in underserved areas more likely to practice there.

Residency lasts at least three years, which is enough time that trainees become part of a community and consider staying, said Brianna Lombardi, director of the University of North Carolina Behavioral Health Workforce Research Center. The programs aren’t easy to set up, though, and rural hospitals likely would need significant federal support to make it happen, she said.

“It’s really easy for the academic centers to train a lot of people, because that’s how they’re set up,” she said.

Increasing the number of medical graduates is only part of the solution, though, said Dr. Robert Cain, president and CEO of the American Association of Colleges of Osteopathic Medicine.

More young doctors need the option to complete their residencies in rural areas, but small hospitals may not be able to handle the upfront cost, which can exceed $150,000 for each resident, he said. The federal government reimburses hospitals for training expenses, but only after the first three years.

And none of that is a substitute for increasing pay and respect for primary care providers, Cain said.

“What we haven’t done is resource primary care and promote primary care so people want to go into it,” he said.

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